MRI

OF
THE ANKLE & FOOT

BY
DR;SAMEH A RAOUF
ASSISTANT PROFESSOR OF RADIO DIAGNOSIS
AIN SHAMS UNIVERSITY

MRI of the ankle and foot

To

arrange
or
create
a
presentation titled MRI of the
ankle and foot, it is a nightmare
because it is quite impossible to
fulfill all what you plan and give
all the examples you want.
Actually you need extended time
may be so many days to satisfy
your self as an educator, mean
time to give
a piece of
information in palatable way so :
These
are
snap
shots
in
mysterious world of imaging of
the ankle and foot.

OBJECTIVES

IMAGING TECHNIQUES
NORMAL ANATOMY
LIGAMENTOUS INJURIES
TENDON LESIONS
BONE LESIONS
REFERENCES

IMAGING TECHNIQUES

On imaging of the foot and ankle the first thing to remember is that you can
NOT get adequate spatial resolution and imaging quality when you scan both
together.

Foot positioning should be fixed from patient to patient.

Alteration of plantar and dorsiflexion alter the anatomic appearance.

Standard internationally accepted anatomic terminology is based on the

following :

The sole of the foot should be 90 degrees with respect to the axis of the leg.

The axial plane ,if the person is standing would be the plane parallel to the
floor.

The coronal plane is at right angle to the axial plane;i.e in the line of long
axis of the tibia.

Instrumentation

Commercial MR systems are available in several configurations.

Systems vary in the strength of the static magnetic field, measured in tesla, in
the size and shape of the opening for the patient, in the available gradients and
coils, in the available pulse sequence options, and of course in size and cost.
Each system has advantages and disadvantages for MR imaging of the foot and

ankle.
The magnetic field strength of clinical MR imaging machines falls into three

broad categories:

High-field (typified by a 1.5-3T).

Mid-field (approximately 0.5-T).

Low-field (0.2-T) scanners.

Position &coil
Patient position:

Ankle and foot is usually placed in a neutral position, although partial

plantar flexion may be useful at 90
Surface Coil:

High resolution anatomic images of the ankle and foot are obtained with a
dedicated extremity surface coil (quadrature or phased-array design).

Forefront imaging is best done with a 10- to 12-cm FOV (unilateral coil).
Hindfoot and ankle imaging requires a 12- to 16-cm FOV (unilateral coil).

512 X 256 or 256 X256 acquisition matrix .

Single joint at a time

Never two to diagnose.

Anatomy

Ankle Bones

Tibia
Fibula
Talus
Dome
Neck

Calcaneus
Medial tubercle
Anterior
process
Posterior
process

FOOT AND ANKLE

ANATOMY

26 bones and 2
sesamoids
Forefoot
Metatarsals
phalanges

Midfoot

5 tarsals

Rearfoot

Talus and
Calcaneus

Anterior Ankle Toms Hairy

Dick

Medial Ankle Tom, Dick and Harry

Anatomy

LIGAMENTOUS INJURIES

LIGAMENTOUS INJURIES

MRI can accurately demonstrate

ligamentous lesions of the ankle, its
indication may be limited to cases:

In which the surgeon may choose to perform a

primary repair.
In cases of double ligamentous lesions in highly
competitive athletes.
In the evaluation of chronic ankle instability after
adequate treatment for ankle sprain.
in the evaluation of lesions often associated with
ligamentous injuries, such as osteochondral
lesions and tendon tears.

What to look for in acute

injuries??

Lack of visualization of the ligament.

Detachment of the ligament from its osseous
insertion.
Thickening of the ligament, high-signal intensity
material (edema or hemorrhage) surrounding the
injured ligament on T2-weighted images with
replacement of the normal signal intensity of the fat,
and extravasation of joint fluid into the adjacent
soft tissues.
Other signs may include contusion of the adjacent
bone, bone avulsion at the ligamentous insertion,
and associated tendon tears.

What to look for in chronic

injuries??

Poor or no visualization of the involved

ligament.
Thickening; striated areas of decreased
signal intensity on T1- and WIs of the
surrounding fat as a result of fibrosis and
scar tissue.
Thinning, elongated, and wavy ligament
contour.

LIGAMENTOUS INJURIES

Distal Tibiofibular Syndesmosis.

Medial Deltoid Ligament Injuries.
Lateral Deltoid Ligament Injuries.
Sinus Tarsi Syndrome

Distal Tibiofibular Syndesmosis.

Isolated ruptures of the syndesmosis

are rare.

Lateral rotation of the talus using the

posterior TFL as a hinge and rupture
of the anterior TFL are the most
frequent mechanisms of injury.

May

be

associated

with

Medial

malleolar fracture or deltoid ligament

tears .

Other mechanism is abduction of the

talus against the fibula, with double
tears of the anterior and posterior
TFL, fibular fracture ,medial malleolar
fracture or MCL tear

LIGAMENTOUS INJURIES

Distal Tibiofibular Syndesmosis.

Medial Deltoid Ligament Injuries.
Lateral Deltoid Ligament Injuries.
Sinus Tarsi Syndrome

Medial Deltoid Ligament

Injuries

+/- TFL tear(s).

+/- MM fibula fracture.
+/Isloated ruptures are rare.
seen either acute or chronic.
seen with inversion sprains or
eversionlateral rotation injury.
High field strength to evaluate
components :
Superficial (tibiocalcaneal,
tibionavicular, posterior
superficial tibiotalar, and
tibiospring ligaments)
Deep (anterior tibio-talar and
posterior deep tibiotalar
ligaments)

Medial Deltoid Ligament

Injuries

Tibiospring
ligament

LIGAMENTOUS INJURIES

Distal Tibiofibular Syndesmosis.

Medial Deltoid Ligament Injuries.
Lateral Deltoid Ligament Injuries.
Sinus Tarsi Syndrome

Lateral Deltoid Ligament Injuries

Lateral deltoid ligament injuries are the most frequent ligamentous lesions of the ankle and
involve about 85% of ankle sprains.

It is estimated that about 20% of patients with complete tears of the lateral deltoid ligament
develop persistent functional instability of the ankle, regardless of the initial treatment.

These patients may become candidates for late ligamentous surgical reconstruction.

The most common mechanism of injury is inversion or internal rotation with plantar flexion of
the foot.

The anterior talofibular ligament is damaged first, followed by the calcaneofibular ligament
as the force of inversion increases. The posterior talofibular ligament is rarely injured.

It has been estimated that inversion injuries of the lateral deltoid ligament result in anterior
talofibular ligament

tears in 66% of cases and that both the anterior talofibular and the calcaneofibular ligaments
are torn

in 20% of cases.

Lateral Deltoid Ligament Injuries

Ankle sprains have been divided into three grades:

Grade I injuries involve micro tears and ligamentous stretch.

Grade II lesions represent partial macroscopic tears,
Grade III lesions involve complete tears.

Grade I and II lesions are normally treated conservatively. Grade III lesions can be treated surgically, although
some clinicians prefer casting or early controlled mobilization.

Joint effusion always accompanies acute or subacute injuries of the lateral deltoid ligament.

The effusion fills the gap within the disrupted anterior talofibular ligament, and this helps in the diagnosis of
these type of injuries via MRI.

Attenuation, irregularity, and surrounding fluid can be seen in partial tears .

In chronic tears of the anterior talofibular ligament, the joint effusion and soft tissue edema are resolved,
making the diagnosis using MRI more difficult.

Thickening and irregularity of the ligament are signs of chronic injury .

Lack of visualization and soft tissue edema can also be seen in acute injuries of the calcaneofibular ligament.

Synovial proliferation and scar tissue at the level of a chronically injured anterior talofibular ligament can
produce swelling and pain in the anterior lateral aspect of the ankle, the so-called anterolateral impingement .

syndrome Thickening of the soft tissues in this location can be seen on MRI

Lateral Deltoid Ligament Injuries

Anterior talofibular
Posterior talofibular
Calcaneofibular ligament

Lateral Deltoid Ligament Injuries

Most
commonly
injured joint among
athletes
85% of all ankle
injuries are sprains
Most
(85%)
are
INVERSION injuries

Lateral Deltoid Ligament Injuries

LATERAL DELTOID LIGAMENT INJURIES(REMOTE

CONSEQUENCES)

Anterolateral
impingement
syndrome.
Axial T1-WI shows irregularity
and lowsignal intensity material
representing scar tissue and
synovial proliferation in the
expected region of the anterior
talofibular ligament (arrow).

LIGAMENTOUS INJURIES

Distal Tibiofibular Syndesmosis.

Medial Deltoid Ligament Injuries.
Lateral Deltoid Ligament Injuries.
Sinus Tarsi Syndrome.

Sinus Tarsi Syndrome.

Sinus tarsi syndrome is a condition presenting clinically with pain in the lateral
aspect of the foot over the sinus tarsi region and a sensation of hindfoot instability.

The most frequent cause of sinus tarsi syndrome is trauma (70%). Inflammatory
conditions such as rheumatoid arthritis and ankylosing spondylitis, as well as foot
deformities (pes cavus, pes planus), can also produce the syndrome.

Inversion injuries to the ankle induce tears of the lateral deltoid ligament,
beginning with the anterior talofibular ligament and followed by the calcaneofibular
ligament. With increasing inversion, the interosseous ligament of the sinus tarsi
can be torn. This leads to instability of the subtalar joint and subsequently chronic
inflammatory synovial reaction.

The MR manifestations of sinus tarsi syndrome include :

Loss of the fatty signal intensity within the sinus tarsi and tarsal canal and hypointensity on T1weighted images and hyperintensity on

T2-weighted images.

manifestations associated with lack of visualization of the ligaments.

Other associated inversion injuries.

Sinus Tarsi Syndrome.

MRI ANATOMY:

Lateral

BONY
ANATOMY

Sinus tarsi

Ant.
process

Tuberosity

TENDON LESIONS

General Considerations and terminology.

Peroneal Tendon Injuries.
Posterior Tibial Tendon Injuries.
Flexor Hallucis Longus Tendon Injuries.
Achilles Tendon Lesions.
Anterior Tibial Tendon Injuries.
Extensor Hallucis Longus Tendon Injuries

General Considerations

Tendinosis

Tenosynovitis

Entrapment

Rupture

Dislocation

General Considerations
Tendinosis:

Is defined as inflammation or degeneration of the tendon substance.

2ry synovial inflammation may occur.

Trauma,overuse,friction,rheumatological disorders may be the underlying factors.

Tenosynovitis:

Is usually produced by either mechanical or inflammatory

irritation to a tendon sheath.

It may be chronic or acute depending on the duration of the provoking process.

Regardless of the etiology, tenosynovitis is frequently noted in conjunction with

degenerative changes and tears within the underlying tendon substance.

Stenosing tenosynovitis may develop as a tendon traverses a local area of constriction.

Tethering is found under the annular ligament, in the tarsal

tunnel (flexor hallucis longus tendon), or over a bony prominence (peroneal

tendons).

General Considerations

Tendon tears:

Chronic (spontaneous) or acute.

Microtears and degeneration must be present before a

tendon is completely severed.

Chronic tears are related to an ongoing strain on the

tendon such as that seen with the posterior and anterior
tibial tendons.

An acute tear usually follows a sudden and forceful

contraction of the muscle e.g.tears of the Achilles
tendons.

Tendon tears:

General Considerations

Dislocation of an ankle tendon is not a

frequent phenomenon.
It is frequently associated with significant
trauma to the ankle.
Dislocation or subluxation mainly involves
tendons that are contained within shallow
grooves, such as the posterior tibial and
peroneal tendons.
Accessory muscles and ligamentous or bony
anomalies can predispose tendons to
dislocation.

TENDON LESIONS

General Considerations and terminology.

Peroneal Tendon Injuries.
Posterior Tibial Tendon Injuries.
Flexor Hallucis Longus Tendon Injuries.
Achilles Tendon Lesions.
Anterior Tibial Tendon Injuries.
Extensor Hallucis Longus Tendon Injuries

Peroneal Tendon Injuries.

Peroneal

tenosynovitis

manifested

on

MRI

is
by

usually
increased

peritendineal fluid.

In chronic tenosynovitis, thickened low

signal

intensity

synovium

(arrows)

encases the peroneus brevis and longus

tendons

Tears of the peroneus longus tendon

are usually found more distally as the
tendon curves around the cuboid
bone or the peroneal tubercle of the
calcaneum.

Dislocation of the peroneal tendons is

a relatively rare phenomenon.

Posterior Tibial Tendon

Injuries

Most tears of the posterior tibial tendon are chronic.

The most common presentation is a progressive and
painful flatfoot deformity in middle-aged and elderly
women with no history of substantial antecedent trauma.

Posterior Tibial Tendon

Injuries

Grade I tear

Grade II tear

Grade III tear

Dislocation of the posterior tibial

tendon

Post severe dorsi flexion

The PTT is out of its

groove and is medial to
the medial malleolus
(short arrow).
There is also :

Complete tear of the

Achilles tendon (curved
arrow).
Flexor hallucis longus
tendon (long arrow).

Flexor Hallucis Longus Tendon

Injuries

Tendinosis

and

tenosynovitis

of

the

flexor hallucis longus tendon are often

related to activities requiring repetitive,
forceful push-off of the forefoot.

Direct irritation of the tendon against

the bony tunnel between the medial
and lateral tubercles of the talus is the
most common cause of these entities.

Normal variants such as a prominent

os-trigonum an accessory ossification
center

present in

75%

to 10%

of

individuals.

Closed rupture of the flexor hallucis

longus is RARE.

Injuries of Tibialis Anterior

Tendon :

The tibialis anterior tendon is the

most

frequently

injured

of

the

anterior ankle tendons.

Tears of this tendon occur in athletes

in the setting of forced plantar flexion
with ankle eversion

Rupture of the tibialis anterior tendon

can

occur

between

the

extensor

retinaculum and the insertion onto

the

medial

first

cuneiform

and

adjacent base of the first metatarsal.

Injuries of Achilles tendon

Common cause of posterior heel pain

Can have pain at insertion or midsubstance of tendon
Generally occurs after overuse.
Achilles tendon injuries include acute and
chronic peritendinosis, tendinosis, and
partial or complete tears.
The Achilles tendon lacks a synovial
sheath.

Partial tear of the Achilles

tendon

Complete tear of the Achilles

tendon

Buckling of the Achilles

tendon

Xanthomas of the Achilles

tendon

Extensor Hallucis Longus

Tendon Injuries

Acute tears of the

extensor
hallucis
longus are very rare.

RETROCALCANEAL BURSITIS

Thought to result from repetitive

microtrauma from footwear
Exam:

Pain with palpation ANTERIOR to achilles

tendon

Treatment:
RICE, NSAIDs
Padded heel counter
Relative rest

Insertional tendinitis and

retrocalcaneal bursitis

BONE LESIONS

Fractures.
Bone Contusion.
Stress Fractures and Acute Posttraumatic
Fractures.
Osteochondral Fractures.
Osteonecrosis.
Transient Bone Marrow Edema.

Bone Contusion.

Stress Fractures and Acute

Posttraumatic Fractures.

Tibial plafond Fractures.

Malleolus Fractures

Calcaneus Fractures(Anterior
process)

Talus Fractures

OSTEOCHONDRAL DEFECT

Can occur with up to 6.5% of ankle

sprains
History:

Pain, swelling, give way, instability, locking,

catching

Consider if ankle sprains do not respond

to 6-8 weeks of conservative therapy
Plain radiographs first
MRI very sensitive and can grade lesion

OSTEOCHONDRAL DEFECT

Osteochondral Fracture

Osteochondral Fracture

Osteonecrosis.

Transient Bone Marrow Edema.

Picture compatible to that of the hip

MORTONS NEUROMA

Damage to or fibrosis of interdigital

sensory nerve

Risk factors

Usually third web space

High heeled shoes, narrow shoes

History
Poorly localized, shock-like pain
Radiates into toes or proximally during
walking

MORTONS NEUROMA

PLANTAR FASCIITIS

Pain at the most

anterior portion of
the heel pad
Medial tubercle
Worst
with
first
step in the morning
or after inactivity
Pain increases with
active dorsiflexion
of first toe

The ideal report

A Alignment ,Adequacy of examination
to be reported , Associating features in
Syndromes ,Abnormal
signals,Apponeurosis.
B Bone, Bone signals, .
C Cartilage, Contusion,Compartmental
tendon, Complications of trauma or
surgery .
D Destruction, Displacement.
L Ligaments (important 6)
S Soft tissue.

TAKE HOME POINTS

MRI is a powerful technique for evaluating the normal anatomical structures and
pathological conditions of the ankle and foot, and clinicians involved in the treatment of
patients with ankle and foot conditions are increasingly depending on this modality.

The diagnosis is based on efficient clinical data, perfect technique and thorough clinicoradiologic correlation.

The most frequent indications of MRI in this area include suspected tendon lesions,
palpable masses, chronic posttraumatic ankle instability, and ankle or foot pain of
unknown etiology.

In tendon lesions, MRI is valuable for discriminating between partial and complete tears.
It can demonstrate the size and location of the tumor and the tumor's relationship with
the neurovascular bundles, but only in few circumstances can it provide sufficient data to
allow the clinician to make a tissue-specific diagnosis. In chronic ankle instability, MRI
can depict ligamentous lesions, but its sensitivity and specificity are yet to be
determined.

Recent reports indicate that MR arthrography may be needed to accurately establish the
presence of a ligamentous tear.

REFERENCES

Magnetic Resonance Imaging (1999) David D. Starkand William G. Bradley, Jr.

Practical MRI of the foot and ankle 2001.

MR Imaging of Deltoid Ligament Pathologic Findings and Associated Impingement Syndromes (2010 ),
Radiographics:751;1-12.

D. J. Theodorou, S. J. Theodorou, S. Farooki, Y. Kakitsubata, and D. Resnick Disorders of the Plantar

Aponeurosis: A Spectrum of MR Imaging Findings Am. J. Roentgenol., January 1, 2001; 176(1): 97 104

Leach R, Jones R, Silva T. Rupture of the plantar fascia in athletes. J Bone Joint Surg Am 1978; 60:537539.

J. A. Narvaez, J. Narvaez, R. Ortega, C. Aguilera, A. Sanchez, and E. Andia Painful Heel: MR Imaging
Findings RadioGraphics, March 1, 2000; 20(2): 333 352

Theodorou DJ, Theodorou SJ, Kakitsubata Y, et al. Plantar fasciitis and fascial rupture: MR imaging
findings in 26 patients supplemented with anatomic data in cadavers. RadioGraphics 2000; 20(special
issue):S181-S197.

Grasel RP, Schweitzer ME, Kovalovich AM, et al. MR imaging of plantar fasciitis: edema, tears, and occult
marrow abnormalities correlated with outcome. AJR Am J Roentgenol 1999; 173:699-701

Thank you